Reactive arthritis: newer developments

Immunologic derangement caused by intestinal dysbiosis and stress is the intrinsic basis of reactive arthritis

Reactive arthritis (ReA) is defined as arthritis resulting from infections in other body parts, such as the gastrointestinal and urogenital tracts. The primary clinical manifestations involve acute-onset and self-limiting asymmetric large joint inflammation in the lower limbs. Although bacterial or chlamydia infections have long been recognized as playing a pivotal role in its pathogenesis, recent studies suggest that antibiotic treatment may perpetuate rather than eradicate chlamydia within the host, indicating an involvement of other mechanisms in Reactive arthritis. Reactive arthritis is currently believed to be associated with infection, genetic marker (HLA-B27), and immunologic derangement. As an autoimmune disease, increasing attention has been given to understanding the role of the immune system in Reactive arthritis. This review focuses on elucidating how the immune system mediates reactive arthritis and explores the roles of intestinal dysbiosis-induced immune disorders and stress-related factors in autoimmune diseases, providing novel insights into understanding reactive arthritis.

Sulfasalazine Microparticles Targeting Macrophages for the Treatment of Inflammatory Diseases Affecting the Synovial Cavity

Rheumatoid arthritis (RA) is a chronic inflammatory disease with sulfasalazine (SSZ) extensively used for long-term treatment of both juvenile and adult RA. Its use is associated with adverse effects and toxicity due to its non-selective biodistribution. Macrophages play an important role in inflammatory processes. In order to target SSZ to macrophages in this work two microparticulate systems (MPs) are developed: SSZ-loaded PLGA MPs without and with α-tocopherol, with particle sizes lower than 5 μm and encapsulation efficiencies of 81.07 ± 11% and 63.50 ± 6.62%, respectively. Release of SSZ from MPs prepared with α-tocopherol was prolonged for 20 days. In RAW 264.7 cell macrophages MPs prepared with α-tocopherol were captured faster. Cell viability studies confirmed that SSZ-loaded MPs prepared without and with α-tocopherol did not produce cytotoxicity at the concentrations assayed. The anti-inflammatory activity of SSZ-loaded MPs was studied by quantifying interleukins IL-1, IL-6 and TNF-α in macrophages. All formulations produced a significant reduction of cytokine concentrations after 24 and 72 h, indicating that release of SSZ from the MPs was able to inhibit the inflammatory response induced by lipopolysaccharide (LPS). Gene expression of IL-1, IL-6 and TNF-α was decreased by SSZ-loaded MPs. SSZ-loaded MPs prepared with α-tocopherol will potentially allow increasing the residence time of SSZ in the synovial cavity, prolonging its duration of action, and reducing the adverse effects associated with its non-selective biodistribution.

British Association of Sexual Health and HIV national guideline on the management of sexually acquired reactive arthritis 2021

These guidelines update the 2008 UK guideline for the management of sexually acquired reactive arthritis. The guideline is aimed at those over the age of 16 years, presenting to healthcare professionals working in sexual health services. The recommendations are primarily aimed at services offering level 3 care in sexually transmitted infection management within the United Kingdom. However, the principles will apply to those presenting to level 1 and 2 services, and appropriate local referral pathways will need to be developed.

Case Report of a Rare Cause of Reactive Arthritis: Leptospirosis

Introduction

Leptospirosis is a zoonosis caused by infection with pathogenic Leptospira species. Leptospirosis has protean manifestations and rare, unusual presentations should be kept in mind in relevant epidemiological scenario. Reactive arthritis refers to acute non-purulent arthritis complicating an infection elsewhere in the body. It is attributed to an immune activation following certain infections; it is, therefore considered as aseptic arthritis. Very few case reports are available attributing leptospirosis as an established cause of reactive arthritis. We present a case of reactive arthritis of the hip joint due to leptospirosis.

Case Report

Here, we present a case of a 12-years- old female child who was admitted to our hospital with complaints of fever, headache, and pain in the right hip joint since past 5 days from admission. Subsequent elaboration revealed a past history of fever, headache, and myalgia for around 5-7 days around a week before the present complaints. There was rat infestation near her house and her father was working as sewage cleaner. Routine investigations, Ultrasonography (USG), Magnetic Resonance Imaging (MRI) of both hips and subsequently, diagnostic hip aspiration was performed. USG revealed synovitis, MRI revealed hip joint arthritis of infective or inflammatory origin. Diagnostic hip aspiration was negative for any microorganism. On 10th day of admission, patient started developing icterus with yellowish discolouration of urine. Patient was evaluated for the cause of jaundice. Screening for Leptospira was positive. Synovial biopsy of hip was performed, which showed inflammation with no specific pathology and no growth of any microorganism. In addition, Leptospira IgM MAC ELISA was done which was positive. Patient was thus confirmed to be having leptospirosis and reactive arthritis as a consequence of it.

Conclusion

The presentation of reactive arthritis secondary to leptospirosis is rare. Leptospirosis can be an etiological factor for reactive arthritis, especially if reactive arthritis is complicated with jaundice.

Clostridium difficile Colitis Leading to Reactive Arthritis: A Rare Complication Associated With a Common Disease

The relationship between reactive arthritis and enteric infections caused by Yersinia enterocolitica, Campylobacter jejuni, and Salmonella typhimurium is well documented. Clostridium difficile colitis is a less recognized cause of reactive arthritis. We present a case of a 58-year-old woman with Clostridium difficile colitis complicated by reactive arthritis. A 58-year-old woman with no significant past medical history presented to our hospital with complaints of nonbloody watery diarrhea, abdominal pain for the past 1 week, and right knee pain starting 1 day prior. The patient had recently used antibiotics for a respiratory tract infection. On examination, the patient had a swollen and erythematous right knee. While in the hospital the patient also developed a similarly painful and swollen left knee. The patient was found to be positive for C difficile toxin in stool. Synovial fluid analysis of both the knee joints revealed a sterile and inflammatory fluid, negative for crystals and showing no growth on gram stain. We diagnosed the patient with reactive arthritis secondary to C difficile colitis once all other causes of the bilateral knee joint symptoms were ruled out with appropriate laboratory and imaging studies. Treatment with oral vancomycin and an anti-inflammatory was initiated, and the patient had complete resolution of symptoms. This case illustrates the importance of recognizing C difficile colitis as a potential differential for reactive arthritis under the appropriate circumstances. The treatment of reactive arthritis is mainly supportive and treating the underlying cause, which happens to be C difficile in this case.

Reactive Arthritis Caused by Yersinia enterocolitica Enteritis

We report a case of reactive arthritis (ReA) triggered by Yersinia enterocolitica enteritis. A 24-year-old Japanese man developed polyarthritis in the lower limbs. Two weeks prior to these symptoms, he noted diarrhea, right lower abdominal pain and a fever. Y. enterocolitica was not isolated from a stool culture; however, he was diagnosed with ReA based on the colonoscopic findings of a high anti-Y. enterocolitica antibody titer and HLA-B27 antigen positivity. Following treatment with methotrexate and steroids, his arthritis improved. This is the first reported Japanese case of ReA in the English literature after a gastrointestinal infection caused by Y. enterocolitica.

Recent advances and future directions in understanding and treating Chlamydia-induced reactive arthritis

INTRODUCTION

Reactive arthritis (ReA) is an inflammatory disease that can follow gastrointestinal or genitourinary infections. The primary etiologic agent for post-venereal ReA is the bacterium Chlamydia trachomatis; its relative, C pneumoniae, has also been implicated in disease induction although to a lesser degree. Studies have indicated that the arthritis is elicited by chlamydiae infecting synovial tissue in an unusual biologic state designated persistence. We review clinical aspects, host-pathogen interactions, and treatments for the disease. Areas covered: We briefly discuss both the historic and,more extensively, the current medical literature describing ReA, and we provide a discussion of the biology of the chlamydiae as it relates to elicitation of the disease. A summary of clinical aspects of Chlamydia-induced ReA is included to give context for approaches to treatment of the arthritis. Expert commentary: Basic research into the biology and host-pathogen interactions characteristic of C trachomatis has provided a wealth of information that underlies our current understanding of the pathogenic processes occurring in the ReA synovium. Importantly, a promising approach to cure of the disease is at hand. However, both basic and clinical research into Chlamydia-induced ReA has lagged over the last 5 years, including required studies relating to cure of the disease.

Salmonella as an Inducer of Autoimmunity

A clear etiological link has been established between infection with several gram-negative enteric pathogens, including Salmonella spp., and the incidence of reactive arthritis (ReA), an autoimmune disease that largely affects the joints. ReA is sometimes referred to as Reiter's syndrome, particularly when accompanied by uveitis and urethritis. This review reviews the evidence etiologically linking Salmonella infection with autoimmune disease and addresses the roles that bacterial and host elements play in controlling disease outcome. ReA is an autoimmune disease that largely consists of painful joint inflammation but also can include inflammation of the eye, gastrointestinal tract, and skin. ReA is a member of a broad spectrum of chronic inflammatory disorders termed the seronegative spondyloarthropathies (SNSpAs) that includes ankylosing spondylitis (AS), psoriatic arthritis, and enteropathic arthritis. Salmonella species, as well as other enteric pathogens associated with postgastroenteritis ReA, are facultative intracellular gram-negative bacteria. Many studies have analyzed the association of the HLA class I molecule, HLA-B27, with SNSpAs. Whereas B27 has been shown to be present in 90 to 95% of cases of AS, the association of the B27 haplotype with other SNSpAs is more tenuous. The clear association between ReA and infection with Salmonella or other gram-negative enteric pathogens has led to the suggestion that the adaptive immune response to infection has an autoimmune component. In addition to various Salmonella species, other gram-negative enteric pathogens have been linked to the development of ReA. Given their close relationship to Salmonella, this review considers the involvement of Shigella species in ReA.

Reactive arthritis

Reactive arthritis (ReA) is an immune-mediated seronegative arthritis that belongs to the group of spondyloarthropathies and develops after a gastrointestinal or genitourinary system infection. The condition is considered to be characterized by a triad of symptoms (conjunctivitis, arthritis and urethritis) although a constellation of other manifestations may also be present. ReA is characterized by psoriasiform dermatological manifestations that may resemble those of pustular psoriasis and, similar to guttate psoriasis, is a post-infectious entity. Also, the articular manifestations of the disorder are similar to those of psoriatic arthritis and both conditions show a correlation with HLA-B27. These facts have led several authors to suggest that there is a connection between ReA and psoriasis, listing ReA among the disorders related to psoriasis. However, the pathogenetic mechanism behind the condition is complex and poorly understood. Bacterial antigenicity, the type of host response (i.e. Th1/Th2 imbalance) and various genetic factors (i.e. HLA-B27 etc.) play an important role in the development of the disorder. It is unknown whether all the aforementioned factors are part of a mechanism that could be similar to, or share basic aspects with known psoriasis pathogenesis mechanisms.

The molecular basis for disease phenotype in chronic Chlamydia-induced arthritis

Genital Chlamydia trachomatis infections can elicit an inflammatory arthritis in some individuals, and recent surprising studies have demonstrated that only ocular (trachoma) strains, not genital strains, of the organism are present in the synovial tissues of patients with the disease. This observation suggests an explanation for the small proportion of genitally-infected patients who develop Chlamydia-induced arthritis. Other recent studies have begun to identify the specific chlamydial gene products that elicit the synovial inflammatory response during both active and quiescent disease, although much more study will be required to complete the understanding of that complex process of host-pathogen interaction. Several newly developed experimental methods and approaches for study of the process will enable identification of new therapeutic targets, and possibly strategies for prevention of the disease altogether.

Of bugs and joints: the relationship between infection and joints

The association between microbes and joints has existed since antiquity, and remains complex. Diagnosis is often times difficult to determine despite highly suspicious clinical characteristics for the presence of an underlying infection. Over the several past decades, considerable advances have occurred in diagnostic methodologies and therapy. However, the morbidity and mortality of septic arthritis remains high. Great advances have occurred in the diagnosis, pathogenesis, and therapeutic management of reactive arthritis, and there is evidence that when the responsible microorganism is Chlamydia trachomathis, complete remission and cure is possible. Emergent infections, especially viral, has been recognized, i.e. HIV, hepatitis C, and most recently Chikengunya virus, and in the case of HIV associated articular manifestations, the introduction of HAART has resulted in a decrease in the incidence and development of newer complications such as the immune reconstitution syndrome. The infectious etiology of rheumatoid arthritis is being strongly considered once again, and the exciting association with periodontal disease is at the forefront of intense research. The gut microbiota is also being investigated and new and most interesting data is being gathered of the potential role of commensal gut organisms and the pathogenesis of rheumatoid arthritis.

Treating reactive arthritis: insights for the clinician

THERE ARE TWO MAIN FORMS OF REACTIVE ARTHRITIS (REA): postvenereal and postdysentery. Chlamydia trachomatis (Ct) is the major causative organism of the postvenereal type; Salmonella, Shigella, Campylobacter, and Yersinia are the major triggers for the postenteric type. All of these causative organisms have been shown to traffic to the synovium in affected individuals. However, one important difference is that the chlamydial organisms have been shown to be viable, whereas, in general, the postenteric organisms are not. Although estimates vary widely, it is felt that 30-50% of all cases of ReA become chronic and the remainder resolve spontaneously within weeks to months. These important differences need to be considered when reviewing the available therapeutic outcomes data. There is a relative paucity of prospective clinical trial data assessing various treatment strategies. A large breadth of clinical experience demonstrates that nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are efficacious, but there have only been two rather small trials assessing NSAIDs and none with corticosteroids. Disease modifying drugs are sometimes utilized in more severe or chronic cases, but only sulfasalazine (SSZ) has been studied. Anti-tumor necrosis factor (TNF) therapy has proved remarkably efficacious with other types of spondyloarthritides, but there is very little data to support their use in ReA; theoretical concerns also exist with this drug class in ReA, specifically. Finally, antibiotics have been studied in several trials. A thorough analysis of these trials reveals equivocal results with a possible particular benefit in postchlamydial ReA. These data are reviewed with an emphasis on postchlamydial and postenteric ReA.

[Diagnosis and treatment of Chlamydia-induced reactive arthritis]

Urogenital chlamydia infections are the most prevalent of all sexually transmitted diseases although the number of chlamydia-induced reactive arthritis cases are generally below the estimated incidence of the disease. This may be related with the high rate of asymptomatic chlamydial infections and the lack of adequate diagnostic criteria. Polymerase chain reaction (PCR), a new system for detection of Chlamydia, is one of the most useful techniques for the diagnosis of this disease. Biologic therapy produces theoretical doubts regarding its indication and there is little information related with chlamydia induced reactive arthritis treatment efficacy. Although the usefulness of long antibiotic treatment is not clear, the use of combination antibiotics opens new therapeutic strategies for chlamydia induced reactive arthritis.

Reactive Arthritis Secondary to Cauda Equina Injury following Spine Fracture: A Case Report

A 38-year-old man presented with a one-month history of muscle weakness and dysesthesia in the lower extremities, urinary retention, and urinary tract infection after lumbar burst fracture resulted from high fall. During the rehabilitation in our hospital, he had arthritis in both the ankle and knee. However, the patient was treated as gouty arthropathy initially. The arthritis was completely remitted in a few days after the patient was diagnosed as reactive arthritis and started with sulfasalazine therapy and there was no recurrence during 4 months of follow-up. Based on this case, early recognition of reactive arthritis is of major importance to avoid delayed initiation of appropriate treatment in the patients with polyarthritis secondary to neurogenic bladder following cauda equina injury after spine fracture.

[Reactive arthritis: from pathogenesis to novel strategies]

Reactive arthritis (ReA) was first described 100 years ago. It is defined as a sterile joint inflammation following a primary, extra-articular infection often in the form of urethritis or enteritis and less frequently respiratory infection and is characterized by the presence of bacterial antigens or non-culturable bacteria in the joint,. The prevalence is estimated to be 40/100,000 adults, while the incidence is 4-5/100,000. The classic HLA-B27-associated form with asymmetric involvement of the lower extremities and/or the spine is part of the spondyloarthritis concept. The phenomenon of persistence, which will be discussed in detail herein, plays an important role in the pathogenesis of ReA. Up to 30% of patients develop chronic symptoms posing a therapeutic challenge. Combination antibiotic treatment showing a response in up to 63% of patients has recently been proposed. Biologics could represent an alternative therapeutic option for patients showing a severe and highly active disease course.

Reactive arthritis: clinical aspects and medical management

Reactive arthritis (ReA) is an inflammatory arthritis that arises after certain gastrointestinal or genitourinary infections, representing a classic interplay between host and environment. It belongs to the group of arthritidies known as the spondyloarthropathies. The classic syndrome is a triad of symptoms, including the urethra, conjunctiva, and synovium; however, the majority of patients do not present with this triad. Diagnostic criteria for ReA exist, but data suggest new criteria are needed. Epidemiologic and prospective studies have been difficult to perform because of over-reliance on the complete classic triad of symptoms and the different terms and eponyms used. Studies assessing various treatment strategies are ongoing.

Arthritis risk after acute bacterial gastroenteritis

OBJECTIVES

Reactive arthritis (ReA) may occur from bacterial gastroenteritis. We studied the risk of arthritis after an outbreak of Escherichia coli O157:H7 and Campylobacter species within a regional drinking water supply to examine the relationship between the severity of acute diarrhoea and subsequent symptoms of arthritis.

METHODS

Participants with no known history of arthritis before the outbreak participated in a long-term follow-up study. Of the 2299 participants, 788 were asymptomatic during the outbreak, 1034 had moderate symptoms of acute gastroenteritis and 477 had severe symptoms that necessitated medical attention. The outcomes of interest were new arthritis by self-report and a new prescription of medication for arthritis during the follow-up period.

RESULTS

After a mean follow-up of 4.5 yrs after the outbreak, arthritis was reported in 15.7% of participants who had been asymptomatic during the outbreak, and in 17.6 and 21.6% of those who had moderate and severe symptoms of acute gastroenteritis, respectively (P-value for trend = 0.009). Compared with the asymptomatic participants, those with moderate and severe symptoms of gastroenteritis had an adjusted relative risk of arthritis of 1.19 [95% confidence interval (CI) 0.99-1.43] and 1.33 (95% CI 1.07-1.66), respectively. No association was observed between gastroenteritis and the subsequent risk of prescription medication for arthritis (P = 0.49).

CONCLUSIONS

Acute bacterial gastroenteritis necessitating medical attention was associated with a higher risk of arthritic symptoms, but not arthritic medications, up to 4 yrs afterwards. The nature and chronicity of these arthritic symptoms requires further study.

Clostridium difficile: an under-recognized cause of reactive arthritis?

Reactive arthritis usually presents as a sterile, inflammatory, asymmetric oligoarthritis, affecting large lower extremity joints. Extra-articular features (conjunctivitis, uveitis, enthesopathy, urethritis, balanitis, keratoderma blenorrhagicum) may occur. Common causes of enteric reactive arthritis are preceding infections attributable to Salmonella, Shigella, Campylobacter, and Yersinia. In contrast, Clostridium difficile is an uncommon cause of reactive arthritis, with only approximately 40 reported cases. We describe a patient with an intense additive, asymmetric oligoarthritis after an antecedent C. difficile infection. The potential contribution of C. difficile to more insidious cases of undifferentiated oligoarthritis is discussed, with emphasis on corresponding therapeutic interventions.

Campylobacter reactive arthritis: a systematic review

OBJECTIVE

To review the literature on the epidemiology of Campylobacter-associated reactive arthritis (ReA).

METHODS

A Medline (PubMed) search identified studies from 1966 to 2006 that investigated the epidemiology of Campylobacter-associated ReA. Search terms included: "reactive arthritis," "spondyloarthropathy," "Reiter's syndrome," "gastroenteritis," "diarrhea," "epidemiology," "incidence," "prevalence," and "Campylobacter."

RESULTS

The literature available to date suggests that the incidence of Campylobacter ReA may occur in 1 to 5% of those infected. The annual incidence of ReA after Campylobacter or Shigella may be 4.3 and 1.3, respectively, per 100,000. The duration of acute ReA varies considerably among reports, and the incidence and impact of chronic ReA from Campylobacter infection is virtually unknown.

CONCLUSIONS

Campylobacter-associated ReA incidence and prevalence varies widely among reviews due to case ascertainment differences, exposure differences, lack of diagnostic criteria for ReA, and perhaps genetics and ages of exposed individuals. At the population level it may not be associated with HLA-B27, and inflammatory back involvement is uncommon. Follow-up for long-term sequelae is largely unknown. Five percent of Campylobacter ReA may be chronic or relapsing (with respect to musculoskeletal symptoms).

Reactive arthritis: defined etiologies, emerging pathophysiology, and unresolved treatment

ReA is unique in that it is one of the few disease states of which there is a known trigger. This insight into disease initiation has led to great advances in the pathophysiology. Despite this detailed knowledge, the proper treatment remains elusive. In the years to come it is possible that the specific treatment will be dictated by the triggering microbe.

Solute Carrier Family 11 Member A1 Gene Polymorphisms in Reactive Arthritis

To investigate the role of SLC 11A1 polymorphisms in the development of reactive arthritis, 91 patients with reactive arthritis and 163 healthy controls were enrolled in this study. The SLC 11A1 polymorphisms were determined by the method of polymerase chain reaction/restriction fragment length polymorphism. The genotype distributions of SLC 11A1 274, 823, 1703, and 1729+ 55 del 4 were significantly different between the patients with reactive arthritis and controls. The genotype frequency of SLC 11A1 274C/C was significantly decreased in the patients with reactive arthritis when compared with that of the controls. In contrast, the SLC 11A1 274C/T showed a significant association with reactive arthritis. The patients with reactive arthritis have a significantly higher frequency of SLC 11A1 823C/C than the controls. However, SLC 11A1 823T/T was resistant to the development of reactive arthritis. The allele frequencies of SLC 11A1 274T and 823C were significantly increased in the patients with reactive arthritis in comparison with those of the controls, independent of HLA-B27. On the contrary, the allele frequencies of SLC 11A1 274C and 823T were significantly decreased in the patients with reactive arthritis. The estimated haplotype frequency of SLC 11A1 274C 823T 1703G 1729+55del 4 TGTG+ was significantly decreased in the patients with reactive arthritis when compared with that of the controls. In contrast, the estimated haplotype frequency of SLC 11A1 274T 823C 1703G 1729+55 del 4 TGTG+ was significantly increased in the patients with reactive arthritis. This study shows that the SLC 11A1 274T and 823C alleles are associated with susceptibility to reactive arthritis independently of HLA-B27 in Taiwan. The SLC 11A1 274T 823C 1703G 1729+55 del 4 TGTG+ haplotype is associated with the development of reactive arthritis in Taiwan. In contrast, the SLC 11A1 274C 823T 1703G 1729+55 del 4 TGTG+ haplotype may be a protective factor.

Reactive arthritis

Reactive arthritis (ReA) has been recognized as a clinical disease entity for nearly 100 years. The prevalence is estimated to be 30-40/100,000 adults. The HLA-B27-associated form is part of the spondyloarthritis concept. According to the current hypothesis the arthritis follows a primary extra-articular infection and is characterized by the presence of bacterial antigen and/or of viable but non-culturable bacteria persisting within the joint. Pathogenesis involves the modification of host cells by pathogen-associated molecular patterns (PAMPs, e.g. lipopolysaccharide), bacterial effector proteins, the adaptive immune system, and the genetic background. Up to 30% of patients develop chronic symptoms, and therapeutic options for these patients are still limited. Data for recommendations to apply conventional disease-modifying anti-rheumatic drugs (DMARDs) are rare; however, sulfasalazine seems to be effective, and first reports on agents that block tumour necrosis factor (TNF) are promising. Combination therapy of several antibiotics might open the window to curing the disease; however, controlled clinical studies are needed.

Clinical presentations of chlamydial and non-chlamydial reactive arthritis

The aim of this study was to investigate the triggering micro-organisms and the clinical as well as laboratory differences between Chlamydial and non-chlamydial reactive arthritis (ReA) in a prospective study on 98 patients with acute/subacute arthritis. An inciting organism was found in 42 patients. Eighteen of these were chlamydial. Fifty-seven percent of all ReA patients were carriers for HLA-B27, which increased to 67% in the chlamydial group. Chlamydial ReA patients had more urethritis (P<0.05) with a longer period between arthritis and inciting infection, significantly lower CRP levels, and involved joint counts (P<0.05). Additionally, sacroiliitis was more frequent besides extra-articular manifestations in chlamydial ReA group. This study shows that chlamydial ReA differs in some points from non-chlamydial ReA, which in turn may affect the evaluation of an arthritic patient. ReA due to chlamydia more frequently encompasses a monoarticular or oligoarticular clinical picture with predominant distal extremity involvement. Non-chlamydial ReA presents higher joint counts and may involve upper extremity joints.

Cat-scratch disease-associated arthropathy

OBJECTIVE

To characterize the articular manifestations of cat-scratch disease (CSD) and to evaluate the long-term clinical outcome of those manifestations.

METHODS

A community- and hospital-based surveillance study of CSD was conducted in Israel between 1991 and 2002. CSD was defined as present in a patient when a compatible clinical syndrome and a positive confirmatory finding of Bartonella henselae (by serology and/or polymerase chain reaction) were identified. CSD patients with arthropathy (arthritis/arthralgia) that limited or precluded usual activities of daily living constituted the study group. Patients were followed up until > or =6 weeks after resolution of symptoms, or if symptoms persisted, for >/=12 months. CSD patients without arthropathy served as controls.

RESULTS

Among 841 CSD patients, 24 (2.9%) had rheumatoid factor-negative arthropathy that was often severe and disabling. Both univariate and multivariate analyses identified female sex (67% of arthropathy patients versus 40% of controls; relative risk [RR] 2.5, P = 0.047), age older than 20 years (100% of arthropathy patients versus 43% of controls; RR 4.9, P = 0.001), and erythema nodosum (21% of arthropathy patients versus 2% of controls; RR 7.9, P = 0.001) as variables significantly associated with arthropathy. Knee, wrist, ankle, and elbow joints were most frequently affected. Ten patients (42%) had severe arthropathy in the weight-bearing joints, which substantially limited their ability to walk, and 4 of these patients were hospitalized. All of the patients had regional lymphadenopathy, 37.5% had nocturnal joint pain, and 25% had morning stiffness. Nineteen patients (79.2%) recovered after a median duration of 6 weeks (range 1-24 weeks), whereas 5 patients (20.8%) developed chronic disease persisting 16-53 months (median 30 months) after the onset of arthropathy.

CONCLUSION

This is the first comprehensive study of arthropathy in CSD. CSD-associated arthropathy is an uncommon syndrome affecting mostly young and middle-age women. It is often severe and disabling, and may take a chronic course.

Recent advances in reactive arthritis

Reactive arthritis (ReA), one of the spondyloarthropathies, is an infectious related disease that occurs in a genetically predisposed individual, characterized by an immune-mediated synovitis with intra-articular persistence of viable nonculturable bacteria and/or immunogenic bacterial antigens. ReA long term prognosis is not as good as it was earlier believed. Two-thirds of patients develop prolonged joint discomfort, low back pain, or enthesopathies after acute ReA, and 15% to 30% of them develop chronic symptoms. The therapeutic options for patients with the more severe forms of the disease have been rather limited. The efficacy of tumor necrosis factor antagonists in other spondyloarthritis suggested that anticytokine therapy could also be effective for ReA. This paper reviews the latest concepts in urogenital and postenteric human leukocyte antigen-B27-associated ReA.

Management of reactive arthritis

Reactive arthritis (ReA) is an aseptic form of articular inflammation induced by infections mainly localised in the gastrointestinal (enteroarthritis) or urogenital (uroarthritis) tracts. The bacteria principally involved as causative agents are Chlamydia, Salmonella, Shigella, Campylobacter and Yersinia. The clinical picture is usually characterised by a mono-oligoarthritis of the lower limbs. Axial involvement is possible and extra-articular manifestations such as enthesitis, tenosynovitis, bursitis and dactylitis are frequent. NSAIDs and sulfasalazine are still the drugs most commonly used in the treatment of ReA. Steroids are administered when inflammatory symptoms are resistant to NSAIDs. Experiences with other DMARDs (disease modifying antirheumatic drugs) such as azathioprine, methotrexate and cyclosporin, have been sporadically reported and they can be employed in patients that are unresponsive to the more usual medicaments. The intake of antibacterials (tetracyclines) may be useful in uroarthritis but have not been so successful in enteroarthrits. In more aggressive cases, or when ReA evolves towards ankylosing spondylitis, TNF-alpha blockers could represent an effective choice.

Chlamydia-induced arthritis

PURPOSE OF REVIEW

Chlamydia-induced arthritis is the most frequent form of reactive arthritis in Western countries. This article gives an overview of the recent findings with respect to diagnosis, pathogenesis, and therapy of the disease.

RECENT FINDINGS

Recent advances in the modification and standardization of polymerase chain reaction techniques give promise to identify Chlamydia more frequently from joint samples. Based on the sequenced chlamydial genome, considerable progress has been achieved in the understanding of the Chlamydia-host cell interaction, indicating that persistence is an alternate state of the bacteria used by Chlamydia to escape the immune system of the host rather than a general stress response. Furthermore, Chlamydia has the ability to reprogram the host cell by chlamydial effector proteins, which are transported from the inclusion into the host cell cytoplasm. The role of HLA-B27 is discussed in view of the pathogenesis of the disease. HLA-B27 should be considered a risk factor for chronic and/or axial disease rather than a true susceptibility factor for the development of Chlamydia-induced arthritis. No progress has been made in terms of causative therapy aiming at eradication of the bacteria. Tumor necrosis factor-alpha blocking agents may represent a new option in cases that are refractory to therapy.

SUMMARY

Molecular biology not only has improved the ability to detect Chlamydia in the joint for diagnostic purposes but also has extended the current understanding of the pathogenesis of the disease. In contrast to this progress, causative therapy of Chlamydia-induced arthritis is still an unfulfilled need.

Outcomes of a multicentre randomised clinical trial of etanercept to treat ankylosing spondylitis

OBJECTIVE

A double blind, randomised, placebo controlled study to evaluate the safety and efficacy of etanercept to treat adult patients with ankylosing spondylitis (AS).

METHODS

Adult patients with AS at 14 European sites were randomly assigned to 25 mg injections of etanercept or placebo twice weekly for 12 weeks. The primary efficacy end point was an improvement of at least 20% in patient reported symptoms, based on the multicomponent Assessments in Ankylosing Spondylitis (ASAS) response criteria (ASAS 20). Secondary end points included ASAS 50 and ASAS 70 responses and improved scores on individual components of ASAS, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), acute phase reactants, and spinal mobility tests. Safety was evaluated during scheduled visits.

RESULTS

Of 84 patients enrolled, 45 received etanercept and 39 received placebo. Significantly more etanercept patients than placebo patients responded at the ASAS 20 level as early as week 2, and sustained differences were evident up to week 12. Significantly more etanercept patients reported ASAS 50 responses at all times and ASAS 70 responses at weeks 2, 4, and 8; reported lower composite and fatigue BASDAI scores; had lower acute phase reactant levels; and had improved spinal flexion. Etanercept was well tolerated. Most adverse events were mild to moderate; the only between-group difference was injection site reactions, which occurred significantly more often in etanercept patients.

CONCLUSIONS

Etanercept is a well tolerated and effective treatment for reducing clinical symptoms and signs of AS.

Health sequelae of human cryptosporidiosis in immunocompetent patients

BACKGROUND

There have been no systematic studies following up the longer term health effects of cases of cryptosporidiosis for which genotype data exist.

METHODS

We report a follow-up study of cases of laboratory-confirmed cryptosporidiosis. Case patients were sent a postal questionnaire asking about a wide range of symptoms occurring within 2 months after their initial diagnosis, and control subjects were sent the questionnaire 2 months after they had been recruited to the original study.

RESULTS

Completed questionnaires were received from 235 case patients and 232 control subjects. For 111 of the case patients, the species of the infecting strain was known; 61 of these strains were Cryptosporidium hominis (human genotype), and 50 were Cryptosporidium parvum (bovine genotype). Forty percent of the case patients reported recurrence of intestinal symptoms after resolution of the acute stage of illness, irrespective of whether infection was with C. hominis or C. parvum. Reports of joint pain (odds ratio [OR], 2.8), eye pains (OR, 2.44), recurrent headache (OR, 2.10), dizzy spells (OR, 1.69), and fatigue (OR, 3.0) were significantly more common in case patients than in control subjects, but only in people who had experienced C. hominis infection. Joint symptoms experienced by case patients were of longer duration than those experienced by control subjects.

CONCLUSIONS

Our results confirm previous reports of a high rate of relapse of gastrointestinal symptoms following recovery from an acute episode of cryptosporidiosis and show that C. hominis but not C. parvum is associated with an increased risk of nonintestinal sequelae. This study demonstrates that the impact of cryptosporidiosis on public health extends beyond that of the acute diarrheal illness and can lead to significant health sequelae.

HLA-B27-associated reactive arthritis: pathogenetic and clinical considerations

Current evidence supports the concept that reactive arthritis (ReA) is an immune-mediated synovitis resulting from slow bacterial infections and showing intra-articular persistence of viable, non-culturable bacteria and/or immunogenetic bacterial antigens synthesized by metabolically active bacteria residing in the joint and/or elsewhere in the body. The mechanisms that lead to the development of ReA are complex and basically involve an interaction between an arthritogenic agent and a predisposed host. The way in which a host accommodates to invasive facultative intracellular bacteria is the key to the development of ReA. The details of the molecular pathways that explain the articular and extra-articular manifestations of the disease are still under investigation. Several studies have been done to gain a better understanding of the pathogenesis of ReA; these constitute the basis for a more rational therapeutic approach to this disease.